ATI RN MATERNAL NEWBORN PRACTICE / MATERNAL
NEWBORN ATI 2019 PRACTICE EXAM
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings
should the nurse report to the provider?
1-Hr Glucose Tolerance Test - 120 mg/dL
Hematocrit - 34%
Fundal Height Measurement - 30 cm
Fetal Heart Rate - 110 bpm - ANSWER: Fundal Height
A fundal height measurement of 30 cm should be reported to the provider. Fundal
height should be measured in centimeters and is the same as the number of
gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore,
the nurse should report this finding to the provider.
1-Hr GTT of 130-140 or greater indicates a need to report to provider.
Hematocrit above 33% is normal
FHR is normal (110-160/min)
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription
for magnesium sulfate IV to treat preterm labor. The nurse should notify the
provider of which of the following adverse effects?
Client reports nausea
Urinary output of 40 mL/hr
Respiratory rate 10/min
Client reports feeling flushed - ANSWER: RR 10/min
The nurse should report a respiratory rate of less than 12/min to the provider,
because this is a manifestation of magnesium toxicity. The nurse should ensure that
the antidote, calcium gluconate, is readily available.
Flushing and nausea are expected, but oliguria (levels of 25-30 mL/hr or less) is a sign
of toxicity.
A nurse is assessing a newborn 12 hr after birth. Which of the following
manifestations should the nurse report to the provider?
Acrocyanosis
Transient strabismus
Jaundice
Caput succedaneum - ANSWER: Jaundice
,Jaundice occurring within the first 24 hr of birth is associated with ABO
incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this
manifestation to the provider.
Everything else is expected
A nurse is admitting a client to the labor and delivery unit when the client states,
"My water just broke." Which of the following interventions is the nurses priority?
Perform Nitrazine testing.
Assess the fluid.
Check cervical dilation.
Begin FHR monitoring. - ANSWER: Begin FHR monitoring.
The greatest risk to the client and her fetus following a rupture of membranes is
umbilical cord prolapse (this is a common test question--Remember, cord
compression is associated with variable decelerations and can happen after ROM).
The nurse should monitor the fetus closely to ensure well-being. Therefore, this is
the priority action the nurse should take.
Other actions are correct, but not priority.
A nurse is performing a physical assessment of a newborn upon admission to the
nursery. Which of the following manifestations should the nurse expect? (select all
that apply)
Yellow sclera
Acrocyanosis
Posterior fontanel larger than the anterior fontanel
Positive Babinski reflex
Two umbilical arteries visible - ANSWER: Acrocyanosis is an expected finding for at
least the first 24 hr following birth. Poor peripheral perfusion leads to bluish
discoloration in the newborn's hands and feet.
Newborns should exhibit a positive Babinski sign following birth. The nurse should
stroke the newborn's foot upward from the heel to the toes. The toes should
hyperextend, and dorsal flexion of the big toe should occur. The absence of this
finding requires neurological evaluation. The Babinski reflex is no longer present
after 1 year of age.
The nurse should observe two arteries and one vein in the umbilical cord. The
presence of only one artery can indicate a renal anomaly.
INCORRECT:
Yellow sclera is an indication of hyperbilirubinemia and is not an expected
manifestation.
Posterior fontanel larger than the anterior fontanel is incorrect. The posterior
fontanel is located on the back of the newborn's head and is a small triangular
shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long.
,It is located on the top of the newborn's head and is larger than the posterior
fontanel.
A nurse is transporting a newborn back to the parent's room following a procedure.
Which of the following actions should the nurse take?
Verify that the parent's identification band matches the newborn's identification
band.
Scan the newborn's identification band to verify their identity.
Check the newborn's security tag number to ensure it matches the newborn's
medical record.
Match the newborn's date and time of birth to the information in the parent's
medical record. - ANSWER: Verify that the parent's identification band matches the
newborn's identification band.
The nurse should verify the newborn's identity every time the newborn is returned
to the parents. The nurse should match the information on the parent's
identification band to the information on the newborn's identification band.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal
visit. Which of the following findings should the nurse report to the provider?
Blood pressure 136/88 mm Hg
Report of insomnia
Weight gain of 2.2 kg (4.8 lb)
Report of Braxton Hicks contractions - ANSWER: A weight gain of 2.2 kg (4.8 lb) in a
week is above the expected reference range and could indicate complications.
Therefore, this finding should be reported to the provider.
All other findings are expected
A nurse is assessing a client who has severe preeclampsia. Which of the following
manifestations should the nurse expect?
2+ deep tendon reflexes
Proteinuria of 200 mg in a 24-hr specimen
Polyuria
Blurred vision - ANSWER: Blurred vision
The nurse should identify that a client who has severe preeclampsia can have
arteriolar vasospasms and decreased blood flow to the retina which can lead to
visual disturbances, such as blurred vision, double vision, or dark spots in the visual
field.
DTR would be 3-4+
Proteinuria would be >500
Oliguria, not polyuria
, A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has
just had an amniocentesis. Which of the following interventions is the nurse's
priority following the procedure?
Check the client's temperature.
Observe for uterine contractions.
Administer Rho(D) immune globulin.
Monitor the FHR. - ANSWER: Monitor FHR
The greatest risk to this client and her fetus is fetal death. Therefore, the priority
nursing intervention is to monitor the FHR following an amniocentesis.
Others are correct, but not priority.
A nurse is developing a plan of care for a client who has preeclampsia and is
receiving magnesium sulfate via an IV continuous infusion. Which of the following
interventions should the nurse include in the plan?
Monitor the client's blood pressure every hour.
Restrict the total hourly intake to 200 mL.
Monitor the FHR continuously.
Administer protamine sulfate for manifestations of toxicity. - ANSWER: Monitor FHR
Continuously
Magnesium sulfate, which is used to prevent seizures in clients who have
preeclampsia, is a high-alert medication that requires close monitoring. The FHR and
uterine contractions should be monitored continuously while the client is receiving
magnesium sulfate.
The nurse should monitor the client's vital signs, including blood pressure, every 15
to 30 min.
The nurse should restrict the client's total hourly intake to no more than 125 mL.
Clients who have preeclampsia can have an alteration in kidney function, leading to
increases in edema.
The nurse should administer calcium gluconate if the client shows manifestations of
magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes,
respiratory depression, slurred speech, and cardiac arrest.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the
New Ballard Score.
Which of the following findings should the nurse expect?
Minimal arm recoil
Popliteal angle of 90°
Creases over the entire foot sole
Raised areolas with 3 to 4 mm buds - ANSWER: Minimal arm recoil
The nurse should expect a newborn who was born at 26 weeks of gestation to have
decreased muscular tone, or minimal arm recoil.
NEWBORN ATI 2019 PRACTICE EXAM
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings
should the nurse report to the provider?
1-Hr Glucose Tolerance Test - 120 mg/dL
Hematocrit - 34%
Fundal Height Measurement - 30 cm
Fetal Heart Rate - 110 bpm - ANSWER: Fundal Height
A fundal height measurement of 30 cm should be reported to the provider. Fundal
height should be measured in centimeters and is the same as the number of
gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore,
the nurse should report this finding to the provider.
1-Hr GTT of 130-140 or greater indicates a need to report to provider.
Hematocrit above 33% is normal
FHR is normal (110-160/min)
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription
for magnesium sulfate IV to treat preterm labor. The nurse should notify the
provider of which of the following adverse effects?
Client reports nausea
Urinary output of 40 mL/hr
Respiratory rate 10/min
Client reports feeling flushed - ANSWER: RR 10/min
The nurse should report a respiratory rate of less than 12/min to the provider,
because this is a manifestation of magnesium toxicity. The nurse should ensure that
the antidote, calcium gluconate, is readily available.
Flushing and nausea are expected, but oliguria (levels of 25-30 mL/hr or less) is a sign
of toxicity.
A nurse is assessing a newborn 12 hr after birth. Which of the following
manifestations should the nurse report to the provider?
Acrocyanosis
Transient strabismus
Jaundice
Caput succedaneum - ANSWER: Jaundice
,Jaundice occurring within the first 24 hr of birth is associated with ABO
incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this
manifestation to the provider.
Everything else is expected
A nurse is admitting a client to the labor and delivery unit when the client states,
"My water just broke." Which of the following interventions is the nurses priority?
Perform Nitrazine testing.
Assess the fluid.
Check cervical dilation.
Begin FHR monitoring. - ANSWER: Begin FHR monitoring.
The greatest risk to the client and her fetus following a rupture of membranes is
umbilical cord prolapse (this is a common test question--Remember, cord
compression is associated with variable decelerations and can happen after ROM).
The nurse should monitor the fetus closely to ensure well-being. Therefore, this is
the priority action the nurse should take.
Other actions are correct, but not priority.
A nurse is performing a physical assessment of a newborn upon admission to the
nursery. Which of the following manifestations should the nurse expect? (select all
that apply)
Yellow sclera
Acrocyanosis
Posterior fontanel larger than the anterior fontanel
Positive Babinski reflex
Two umbilical arteries visible - ANSWER: Acrocyanosis is an expected finding for at
least the first 24 hr following birth. Poor peripheral perfusion leads to bluish
discoloration in the newborn's hands and feet.
Newborns should exhibit a positive Babinski sign following birth. The nurse should
stroke the newborn's foot upward from the heel to the toes. The toes should
hyperextend, and dorsal flexion of the big toe should occur. The absence of this
finding requires neurological evaluation. The Babinski reflex is no longer present
after 1 year of age.
The nurse should observe two arteries and one vein in the umbilical cord. The
presence of only one artery can indicate a renal anomaly.
INCORRECT:
Yellow sclera is an indication of hyperbilirubinemia and is not an expected
manifestation.
Posterior fontanel larger than the anterior fontanel is incorrect. The posterior
fontanel is located on the back of the newborn's head and is a small triangular
shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long.
,It is located on the top of the newborn's head and is larger than the posterior
fontanel.
A nurse is transporting a newborn back to the parent's room following a procedure.
Which of the following actions should the nurse take?
Verify that the parent's identification band matches the newborn's identification
band.
Scan the newborn's identification band to verify their identity.
Check the newborn's security tag number to ensure it matches the newborn's
medical record.
Match the newborn's date and time of birth to the information in the parent's
medical record. - ANSWER: Verify that the parent's identification band matches the
newborn's identification band.
The nurse should verify the newborn's identity every time the newborn is returned
to the parents. The nurse should match the information on the parent's
identification band to the information on the newborn's identification band.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal
visit. Which of the following findings should the nurse report to the provider?
Blood pressure 136/88 mm Hg
Report of insomnia
Weight gain of 2.2 kg (4.8 lb)
Report of Braxton Hicks contractions - ANSWER: A weight gain of 2.2 kg (4.8 lb) in a
week is above the expected reference range and could indicate complications.
Therefore, this finding should be reported to the provider.
All other findings are expected
A nurse is assessing a client who has severe preeclampsia. Which of the following
manifestations should the nurse expect?
2+ deep tendon reflexes
Proteinuria of 200 mg in a 24-hr specimen
Polyuria
Blurred vision - ANSWER: Blurred vision
The nurse should identify that a client who has severe preeclampsia can have
arteriolar vasospasms and decreased blood flow to the retina which can lead to
visual disturbances, such as blurred vision, double vision, or dark spots in the visual
field.
DTR would be 3-4+
Proteinuria would be >500
Oliguria, not polyuria
, A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has
just had an amniocentesis. Which of the following interventions is the nurse's
priority following the procedure?
Check the client's temperature.
Observe for uterine contractions.
Administer Rho(D) immune globulin.
Monitor the FHR. - ANSWER: Monitor FHR
The greatest risk to this client and her fetus is fetal death. Therefore, the priority
nursing intervention is to monitor the FHR following an amniocentesis.
Others are correct, but not priority.
A nurse is developing a plan of care for a client who has preeclampsia and is
receiving magnesium sulfate via an IV continuous infusion. Which of the following
interventions should the nurse include in the plan?
Monitor the client's blood pressure every hour.
Restrict the total hourly intake to 200 mL.
Monitor the FHR continuously.
Administer protamine sulfate for manifestations of toxicity. - ANSWER: Monitor FHR
Continuously
Magnesium sulfate, which is used to prevent seizures in clients who have
preeclampsia, is a high-alert medication that requires close monitoring. The FHR and
uterine contractions should be monitored continuously while the client is receiving
magnesium sulfate.
The nurse should monitor the client's vital signs, including blood pressure, every 15
to 30 min.
The nurse should restrict the client's total hourly intake to no more than 125 mL.
Clients who have preeclampsia can have an alteration in kidney function, leading to
increases in edema.
The nurse should administer calcium gluconate if the client shows manifestations of
magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes,
respiratory depression, slurred speech, and cardiac arrest.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the
New Ballard Score.
Which of the following findings should the nurse expect?
Minimal arm recoil
Popliteal angle of 90°
Creases over the entire foot sole
Raised areolas with 3 to 4 mm buds - ANSWER: Minimal arm recoil
The nurse should expect a newborn who was born at 26 weeks of gestation to have
decreased muscular tone, or minimal arm recoil.
